infections such as candidiasis, herpes simplex, oral hairy leukoplakia, and bacterial gingivitis/periodontitis;
Kaposi's sarcoma or lymphoma in the oral cavity.
The client will have a healthy oral cavity as evidenced by:
absence of inflammation
pink, moist, intact mucosa
absence of lesions
no reports of oral dryness and pain
ability to swallow without discomfort.
Nursing Actions and Selected Purposes/Rationales
Assess client for and report signs and symptoms of altered oral mucous membrane (e.g. inflamed and/or ulcerated oral mucosa; corrugated, white thickenings, particularly on sides of tongue; painful vesicles that ulcerate; white plaques that can easily be scraped off; cracks and fissures at corner of mouth; reddened and retracted gingivae; reports of oral dryness and pain; dysphagia; positive results of cultured specimens from oral lesions).
Implement measures to prevent breakdown of the oral mucous membrane and promote healing of existing lesions:
reinforce importance of and assist client with oral hygiene after meals and snacks; avoid use of products that contain lemon and glycerin and mouthwashes containing alcohol (these products have a drying and irritating effect on the oral mucous membrane)
have client rinse mouth frequently with warm saline; baking soda and water; or a solution of salt, baking soda, and water
use a soft bristle toothbrush or a sponge-tipped swab for oral hygiene
lubricate client's lips frequently
encourage client to breathe through nose rather than mouth in order to reduce mouth dryness
encourage a fluid intake of at least 2500 ml/day unless contraindicated
perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c)
encourage client not to smoke or chew tobacco (smoking dries the mucosa; tobacco acts as an irritant to the oral mucosa)
instruct client to avoid substances that might further irritate the oral mucosa (e.g. hot, spicy, or acidic foods/fluids)
administer antimicrobial agents (e.g. clotrimazole troches, nystatin, fluconazole, itraconazole, ketoconazole, acyclovir, foscarnet, cidofovir topical gel) as ordered
if periodontal disease is present, administer the following if ordered: